As the CMS seeks to simplify the application process for exchange plans and Medicaid, payers want to make it harder for individuals to sign up after open enrollment ends. Meanwhile, advocates and providers want to decrease barriers and have the agency learn more about who is signing up, including their sexual orientation.

The suggestions are in response to a request for comment on ways the CMS should overhaul the enrollment process and applications for Medicaid, the Child's Health Insurance Program and health plans on federal and state exchanges.

Between 2017 and 2019, the CMS estimates that more than 21 million newly eligible people will enroll in exchange plans, Medicaid or CHIP as more states are expected to expand their eligibility for enrollment. The agency is looking for ways to streamline applications but also collect more information on who is signing up.

Last month, the CMS eliminated several categories of circumstances that allow consumers to get plans through the marketplaces outside the open-enrollment period. The agency announced plans to eliminate six of the 30 categories of special enrollment, including situations where technology woes impacted coverage.

The announced changes aren't enough, though, plans argue. “More needs to be done,” Aetna CEO Mark Bertolini said during an earnings call on Feb. 1.

“The lack of predictability and full transparency of the risk-adjustment program, which is key to long-term program health … limits our ability to offer affordable, innovative on-exchange products,” he said.

Insurers have been caught off guard by the amount of people who gain coverage through special enrollment periods, according to America's Health Insurance Plans.

The current list of criteria allowing a person to enroll during these periods is expansive and negatively impacts the risk pool of exchange enrollees, AHIP said. People gaining coverage through these periods are incurring higher costs than the rest of the marketplace's risk pool.

The CMS should ask for documentation to verify a person is eligible for a special-enrollment period, AHIP said. If they can't furnish proof, issuers should be able to cancel their policies.

Further, a person shouldn't qualify for special enrollment if they recently lost coverage because of non-payment of premiums, AHIP said.

The CMS should change the way it verifies a person's identity for enrollment purposes, said Families USA, the patient advocacy organization.

Currently, the identification process relies on credit histories alone. That poses significant problems for many uninsured individuals who may have limited credit histories, are legal immigrants but don't have lines of credit, and those who are victims of identity theft, according to the organization.

Families USA recommended expanding the data sources during the identity proofing process to include information enrollees may have provided to other state programs. In addition, applicants should be able to continue with the application process and submit an application before the full ID proofing process is complete. This will ensure that the identity proofing process does not bar consumers from getting coverage.

The agency should also allow minors to apply without an adult, added the National Health Law Program. Some minors may be emancipated and thus are lawfully recognized as independent of their parents or be homeless.

As part of the application process, the CMS asks a series of optional demographic questions such as race and primary language spoken, and the agency should add sexual orientation to that list, Planned Parenthood said.

That would give the CMS a more comprehensive understanding of outreach and enrollment efforts, the not-for-profit family planning organization said.

Tracking sexual orientation also puts the agency in a better position to identify potential disparities in access to health coverage and care, said Heron Greenesmith, a Policy Analyst at the LGBT think tank Movement Advancement Project says.

In her comments, Greenesmith noted that the bisexual population faces lower rates of health insurance coverage than lesbian, gay, and straight counterparts, and transgender people face even lower rates. Tracking when and where LGBT people are signing up for coverage could shed more light on why this is occurring.